IYG Therapy Program | SimplePractice

Your info

First name

Last name

Phone

Client's info

Is the client a minor?

Yes No

First name

Last name

Phone

Administrative

Referral source

How did you hear about our mental health therapy program?

IYG Center Staff Member IYG Mental Health Services Flyer IYG Social Media Physical or Mental Healthcare Provider (outside of IYG) GSA Club or Indiana GSA Network Friend, Family, or Community Member Prefer Not to Answer Other

Referral Source's Name

Only required if the person receiving care is being referred by an IYG staff member, social worker, or another outside provider.

Referral Source's Phone Number

Only required if the person receiving care is being referred by an IYG staff member, social worker, or another outside provider.

Parent or Guardian's Name

Only required if the person completing this form is under the age of 18. Please type "NA" if this is not applicable.

Parent or Guardian's Phone Number

Only required if the person completing this form is under the age of 18. Please type "NA" if this is not applicable.

Parent or Guardian's Email

Only required if the person completing this form is under the age of 18. Please type "NA" if this is not applicable.

Client Preferences

Preferred appointment times

Please note that the IYG's Mental Health Therapists have varied availability. We cannot provide any guarantees, but we will do our best to accommodate your preferences.

Morning (9:00AM-12:00PM) Early Afternoon (12:00PM-3:00PM) Late Afternoon/Early Evening (3:00pm-6:00PM)

Preferred setting

Please note that there is limited in-person availability at our Indianapolis and Columbus centers. At this time, in-person therapy services are not offered at the Crawfordsville, Evansville, or Crown Point centers.

In-person at the Indianapolis Center In-person at the Columbus Center Telehealth

Preferred method of contact

Email Phone Call Text

Do you have any preferences for a therapist?

Please note that the IYG Therapy Program has a limited number of therapists. We cannot provide any guarantees, but we will do our best to accommodate your preferences.

Limited to 600 characters

Reason for care

What is the reason for seeking care?

Adjusting to a major life change Anger/Frustration management Anxiety Depression Grief/Loss High stress Relationship issues Self-esteem or self-image Other

What is the client's date of birth?

Please note that IYG only services young people ages 12-24. If the client is outside of this age range, they will be automatically removed from the waitlist.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.